psicosocial surgery.pdf

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Surgical-orthodontic treatment (orthognathic

surgery) is now a well-established and commonly

used treatment approach for persons with skeletal

discrepancies beyond the scope of conventional ortho-

dontic treatment. Combined orthodontic and surgical

treatment aims to produce more harmonious facial

skeletal relationships and to improve occlusal function,

although this is rarely the primary reason that patients

seek treatment. Research has shown that most patients

who request surgical-orthodontic treatment do so

because of a desire to improve their facial and dental

appearance and not as a result of concerns about

occlusal function.1 This suggests that the major poten-

tial benefits of surgical-orthodontic treatment to the

patient are most likely to be less social embarrassment

and improved self-esteem and self-confidence. Clini-

cians who work in this field can provide anecdotal evi-

dence of the improvement in psychosocial well-being

that surgical-orthodontic treatment brings to their

patients. However, modern health care demands a

higher level of evidence, particularly for lengthy and

expensive interventions that have well-recognized risks.

The aim of this systematic review was to evaluate

the research studies that have examined the psychoso-

cial benefits of surgical-orthodontic treatment. System-

atic reviews locate, appraise, and synthesize the evi-

dence from scientific studies to provide informative

empirical answers to scientific research questions by

including a comprehensive summary of the available

evidence.2 The method adopted in this review was sim-

ilar to that recommended by the United Kingdoms

National Health Service Centre for Reviews and Dis-

semination.2

This review addressed 3 important questions:

1. Does orthognathic surgery result in psychosocial

benefits for the patient?

2. What, if any, are the psychosocial benefits derived

from orthognathic surgery?

3. Are the psychosocial benefits transitory or long-

term?

METHOD

A search for relevant articles was undertaken with

the sources detailed below. No language restrictions

were imposed, and all available years were included.

Journals selected for hand-searching were examined

from January 1984 to December 2000.

MEDLINE is a database produced by the United

States National Library of Medicine and is widely rec-

ognized as the premier source for bibliographic and

From Queens University, Belfast, Northern Ireland.aResearch Assistant, Department of Orthodontics, School of Dentistry.bLecturer in Orthodontics, Department of Orthodontics, School of Dentistry.cProfessor of Psychology, School of Psychology.dConsultant Orthodontist, Department of Orthodontics, School of Dentistry.

Reprint requests to: Orlagh Hunt, Department of Orthodontics, School of Den-

tistry, Queens University Belfast, Grosvenor Road, Belfast BT12 6BP, North-

ern Ireland; e-mail, [email protected].

Submitted, January 2001; revised and accepted, March 2001.

Copyright 2001 by the American Association of Orthodontists.

0889-5406/2001/$35.00 + 0 8/1/118402

doi:10.1067/mod.2001.118402

REVIEW ARTICLE

The psychosocial impact of orthognathic

surgery: A systematic reviewOrlagh T. Hunt, MSc, BSc,a Chris D. Johnston, PhD, BSc, BDS, FDS, M OrthRCS (Edin), FDS (Orth),b

Peter G. Hepper, PhD, BSc, C.Psychol, FBPsS,c and

Donald J. Burden, PhD, MSc, BDS, FDSRCS, FDSRCPS, FFDRCSI, M OrthRCSd

Belfast, Northern Ireland

The aim of this study was to review the reported psychosocial benefits of orthognathic surgery. A systematic

review of the literature was conducted using MEDLINE (1966 to December 2000), Web of Science (1981 to

December 2000), and reference sections of identified articles. We also hand searched key orthodontic, oral

surgery, and psychology journals. No language limitations were imposed. Randomized controlled trials, other

controlled clinical trials, prospective studies (with or without controls), and retrospective studies (with or

without controls) were considered for inclusion. Two reviewers extracted the data and independently assessed

the quality of the studies. In all, 29 studies, including a number of prospective and retrospective studies, were

identified as relevant.The results of the review indicated that orthognathic patients experience psychosocialbenefits as a result of orthognathic surgery, including improved self-confidence, body and facial image, and

social adjustment. However, there were wide variations in the study designs and a lack of uniformity in

measuring the psychosocial constructs. This made it difficult to quantify the extent and the duration of the

psychosocial benefits. (Am J Orthod Dentofacial Orthop 2001;120:490-7)


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American Journal of Orthodontics and Dentofacial Orthopedics Hunt et al 491Volume 120, Number5

abstract coverage of biomedical literature. It encom-

passes information from the Index Medicus, the Index

of Dental Literature, the International Nursing Index,

and other sources in allied health areas. The databasecontains more than 9.5 million records from more than

3900 journals and selected monographs of congresses

and symposia. Our MEDLINE search was based upon

the following terms: orthognathic, surgery, surgical,

surgical-orthodontic, orthodontic, jaw, psychosocial,

psychological, psychology, social, outcome. The

Boolean operator and was used with these words to

narrow the searches.

PsycINFO is a database containing citations and

summaries of journal articles, book chapters, books,

and technical reports, as well as citations to disserta-

tions. It relates to all fields of psychology and psycho-

logical aspects of related disciplines such as medicine,

physiology, psychiatry, nursing, sociology, and educa-tion. More than 1300 journals in over 25 languages are

included in the database. For the systematic review,

PsycINFO was searched with the same terms as used to

search MEDLINE.

Both the Science Citation Index and the Social Sci-

ence Citation Index were accessed through the Web of

Science database. Searching was based on the same

terms as the MEDLINE and PsycINFO searches. The

Web of Science is a platform for accessing a number of

multidisciplinary databases with searchable abstracts

covering the journal literature of the sciences and the

social sciences. The Science Citation Index indexes

more than 5700 major journals in 164 scientific disci-

plines. The Social Science Citation Index indexes more

than 1725 journals in 50 disciplines and covers individ-

ually selected relevant items from over 3300 of the

worlds leading scientific and technical journals.

The reference sections of all relevant articles were

also examined to identify further studies suitable for

inclusion in the review.

Hand searching was conducted on the following

journals from 1984 to December 2000: European Jour-

nal of Orthodontics;American Journal of Orthodontics

and Dentofacial Orthopedics;British Journal of Ortho-

dontics; International Journal of Adult Orthodontics

and Orthognathic Surgery (first published in 1986);

Journal of Clinical Orthodontics; Clinical Orthodonticsand Research (first published in 1998);Journal of Oral

and Maxillofacial Surgery; Plastic and Reconstructive

Surgery; Oral Surgery, Oral Medicine and Oral Pathol-

ogy; andBritish Journal of Oral Surgery. The following

psychology journals were also hand searched: Journal

of Consulting and Clinical Psychology,British Journal

of Social and Clinical Psychology, andAmerican Jour-

nal of Psychology.

Randomized controlled trials, prospective studies

with controls, prospective studies without controls, ret-

rospective studies with controls, and retrospective stud-

ies without controls were considered for inclusion in thereview. Studies that used interviews (structured, semi-

structured, and unstructured), questionnaires (standard-

ized and unstandardized), or clinical examinations com-

bined with either or both previous methods were also

considered suitable.

The review concerned studies of patients who were

considering orthognathic surgery or were about to

undergo orthognathic surgery, and patients who had

completed orthognathic surgery. Studies focusing on

patients with syndromal conditions such as cleft lip and

palate were not included. Only studies in which patients

self-reported their psychosocial status were considered.

Overall, 1173 articles were identified through MED-

LINE searches. When the search was narrowed toinclude only articles concerning the psychosocial

aspects of orthognathic surgery, 112 articles were iden-

tified. No additional articles were identified through

Institute for Scientific Information Web of Science and

PsycINFO searches. Examination of the titles and

abstracts of the 112 articles revealed that 54 were rele-

vant to this review, and full-text versions of these papers

were obtained. Two non-English papers (Japanese and

Italian) were also identified, and translations were

obtained. Examination of the full-text papers revealed

that 3 were literature reviews, and the reference sections

of these articles were consulted to identify other relevant

articles. Three further articles were found in this way.

The full text of the non-English papers subsequently

revealed that only the Japanese paper was suitable for

inclusion in the review. Twenty-eight of the original

papers identified were found to be unrelated to the topic

under review. Hand searching of journals revealed 2

additional relevant articles. This made 29 relevant arti-

cles suitable for inclusion in this systematic review.

THE REVIEW

This review revealed that a wide variety of study

designs has been used to examine the psychosocial ben-

efits of orthognathic surgery, including cohort studies

with controls, prospective studies, and retrospective

studies. Table I shows the number of studies relative totheir level of scientific evidence. This form of hierar-

chical scale is recommended by the National Health

Service (NHS) Centre for Reviews and Dissemination.2

In this hierarchy of clinical evidence, randomized con-

trolled trials provide the strongest evidence of treatment

efficacy, and cross-sectional studies are the weakest

form of evidence. The systematic review revealed that

no randomized trials have been completed in this area.


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492 Hunt et al American Journal of Orthodontics and Dentofacial OrthopedicsNovember 2001

Although a variety of measurement instruments have

been used to evaluate the psychosocial status of ortho-

gnathic patients, the validated questionnaire has been

used most often. The various types of validated ques-

tionnaires are listed in Table II. Further information on

each study is given in Table III.

The highest level of scientific evidence found in this

review was a cohort study with concurrent controls

completed by Kiyak et al.3 Of the 29 studies reviewed,

this is the only one that included a control group. The

authors compared the psychological status of 156

patients who were referred for possible orthognathic

surgery. Ninety of them eventually received orthog-

nathic surgery, 33 declined orthognathic surgery but

underwent orthodontic treatment only, and 33 declined

any form of treatment. The authors reported that the

group that had surgery expressed a significantly more

positive mood, more vigor, less fatigue, less depression,

and less tension-anxiety 6 months after surgery com-

pared with those who completed orthodontic treatment

only and those who had no treatment.3

Although having a control group normally makes a

study more credible, there were several concerns about

the validity of the control group in that investigation.

First, the authors used a control group of patients withuntreated dentofacial deformities. Since the aim of

orthognathic surgery is to bring a patients facial and

dental appearance within the normal range, it would be

more appropriate to use a control sample of subjects

with normal facial and dental appearance. In addition,

the groups were not age matched; the subjects in the

control group were significantly older than were the

patients in the 2 treatment groups.

All 16 uncontrolled prospective studies identified by

this review were longitudinal. Among these studies, a

series of papers produced by Kiyak et al4-7 presents per-

haps the most comprehensive evidence of the psycho-

logical benefits of orthognathic treatment. In a study

published in 1981, Kiyak et al4 examined whether there

were any differences in psychological functioning

between male and female surgery patients before and

after surgery. Very few significant differences emerged

on measures of personality between the sexes either

before or after surgery. However, before surgery, males

were significantly more satisfied with their facial pro-

files than were females (P < .03), but 1 month after

surgery males were less satisfied than females (P

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